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<br /> .� �A�'�� J ���V�� �°�I�'`�Y ����0��`�f��
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET, EVERETT, WA 98201
<br /> (P) 425-257-8810 � FAX 425-257-8857 � (E) everetteps@everettwa.gov � www.everettwa.gov/permits
<br /> PROJECT SITE IWFORMATION
<br /> PROJECT ADDRESS: ���� � ji �/� ��� � ��
<br /> IF APPLICABLE: ❑ OUTSIDE CITY LIMIT ❑ BUILDING AREA SF ❑ LOT#
<br /> BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY�#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL
<br /> CHANGE OF USE? � N� ❑YES, FROM TO
<br /> UTILITIf APPLICATION INFORMATION
<br /> SEWER (check all that apply) WATER(check all that apply)
<br /> ❑ SIDE SEWER REPAIR ❑ NEW WATER SERVICE INSTALLATION
<br /> ❑ SIDE SEWER ALTERATION ❑ COMPLETE SERVICE ❑ METER ONLY
<br /> ❑ NEW SIDE SEWER INSTALLATION SERVICE 1 METER USE:
<br /> �INSTALL BACKWATER VALVE(outside the building) ❑ SFR
<br /> ❑ SIDE SEWER CAP-OFF ❑ MULTI-FAMILY-#OF UNITS:
<br /> ❑ SIDE SEWER RECONNECTION ❑ COMMERCIAL
<br /> MULTIPLE DOPJIESTlC WATER SFRVlCES RE�UEST WATER SERVICF TYPF/SIZE: (circle desired size)
<br /> ❑ I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR ❑ DOMESTIC: 3/4", 1", 2", OTHER:
<br /> MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. ❑ IRRIGATION: 3/4", 1", 2", OTHER:
<br /> ❑ I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER ❑ FIRE: 1", 2", 4", 6", 8", OTHER:
<br /> SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER ❑ DOMESTIC/FIRE COMBO: 1", 2", OTHER:
<br /> SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM.
<br /> CONTACT INFORMATION
<br /> OWNER NAME: TENANT NAME(If Commercial):
<br /> OWNER MAILWG ADDRESS: srREET
<br /> CITY STATE ZIP
<br /> OWNER PHONE: OWNER EMAIL:
<br /> CONTRACTOR NAME: �• 'g � ! ' '� �� � / �'+�
<br /> CONTRACTOR ADDRESS: sTReeT � ``�,� ���✓� �'� ;' '`'��"
<br /> d� �• � _.
<br /> CITY ��` ' ',,r�' -� STATE � ��J ZIP ��
<br /> CONTRACTOR PHONE � !/� ��;��� �� CONT CTOR EMAIL:�% ,,a°�,' �j,';,j`�'�;��� �^�� ��`. �-,A-�� �����y�-�.' • 1; �
<br /> CONTRACTOR LIC.#(REQUIRED): fl � ,6�,,°�'`� � �'� � �'�'�� CITY OF EVERETT BUSWESS'C1C.#(REQUIRED): �j �1�1'� "
<br /> PRIMARY CONTACT: ❑OWNER ❑ CONTRACTOR ❑OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: ���-� / ��� L C y �
<br /> "•f �� �` �'3 � CONTACT EMAIL: �' '� � ✓ � /
<br /> L,��,, �-�,� �����I � ��,� � , ���� �, I �� 2�a������-�- ;�, � �, � ti
<br /> AGREEMENT:The unde�signed applicant agrees to comply with all provisions of the Everett Municipal Code Title � City of Everetf` icial Use Only
<br /> 14 Water and Sewer or such ofher�ules and regulations now existing or which may 6e established from time to FEE
<br /> fime. The applicant further agrees, as a condition precedent to receiving service that the utilities division shall have ✓7 �(�
<br /> the rrght at any time, withouf notice,to shut off o�tum on fhe wafer supply fo�repairs, consfruction, and `� / � �i
<br /> nonpaymenf of charges or for any ofher reasonable cause.I am the owner, or!am authorized by the owner of this d
<br /> property to perform the work for which application is made,a��d I comply with the State Contractors Law 18.27 PERMIT# �
<br /> RCW�nd 296.201�A WAC. � �, ,
<br /> �i����:�,'�.--) ''" !l�� ,X)�1' /1��' f,✓���, �t`� � �' 1 ����' � " ` �� �� 6�}
<br /> Owner/Authorized Agent Signafure D"ate (Revised 10/12/2095)
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